Sexually transmitted infections (STIs) such as HIV and syphilis can pose significant health risks for people who contract them and also create public health concerns if they spread. Safer sex can help to mitigate these risks, particularly for female sex workers who have a higher exposure to STIs. In Tanzania, researchers are evaluating whether cash incentives motivated female sex workers to practice safer sex with their clients and reduce their likelihood of contracting STIs.
HIV risk remains a challenge in low- and middle-income countries. Females engaging in sex work are at extra high risk, especially when they face difficult economic conditions and have limited access to adequate health services. One meta-analysis found that female sex workers in developing countries have 14 times higher odds of being infected with HIV compared to the rest of the population. Policymakers have introduced various interventions to reduce STI and HIV risk, namely providing condoms at cheap prices, which are generally considered as cost-effective methods to keep sex workers and their clients healthy and safe from STI transmission. However, usage of condoms in sex work settings can vary, which can in turn make it difficult to effectively reduce STI and HIV infection rates for female sex workers.
Evidence from across low- and middle-income countries has shown that conditional economic incentives can stimulate individuals’ participation in beneficial activities at a low cost like school enrollment and health check ups. However, research is limited about the impact of cash incentives in HIV prevention contexts specifically.
This team’s prior work in Tanzania suggests that cash incentives can be effective at incentivizing safer sex practices among the general population, and potentially among female sex workers.. A previous randomized evaluation in Ifakara, Tanzania evaluated the effectiveness of cash incentives to practice safer sex as an HIV/STI prevention strategy, focusing on males and females aged 18-30 in the general population. The findings revealed beneficial impacts of cash in reducing STI incidence, particularly among poorer and rural households. A follow-on pilot intervention among female sex workers was also promising, but further study is needed.
Female sex workers in Tanzania have higher rates of HIV infection than other adult females, with an estimated HIV prevalence at nearly 27 percent. Much of the sex work activity occurs in the largest city, Dar Es Salaam. The prevalence of HIV among female sex workers there is estimated at 31.4 percent. The Tanzanian government has intensified efforts recently to provide pre-care and treatment services for sex workers while encouraging them to practice safer sex with their clients to reduce HIV and other STI risk. However, female sex workers in Dar es Salaam do not always practice safer sex with their clients, reporting that in instances when a condom isn’t used with a client, it was largely because the client objected to using one or paid more in order not to use one.
In Tanzania, researchers partnered with Pastoral Activities and Services for people with AIDS Dar es Salaam Archdiocese (PASADA) to measure whether cash incentives can motivate female sex workers to practice safer sex with clients and reduce their likelihood of contracting STIs.
This intervention takes place in Dar Es Salaam and is a follow-up to the Ifakara intervention to determine whether the observed positive impacts of cash incentives on reducing STI incidence could be replicated in a location where HIV prevalence was higher. Furthermore, because female sex workers in Dar Es Salaam have higher than normal rates of contracting STIs than females in the city’s general population, and because of the risk of further spreading HIV and STIs to clients, researchers tailored the program to focus on this population.
To evaluate the impact of cash incentives on motivating safer sex practices and reducing STI incidence among female sex workers, researchers selected 2,206 HIV-negative female sex workers in Dar Es Salaam to participate in the intervention. All were screened for HIV and STIs at the outset and were offered free treatment if they tested positive for curable STIs. They also received pre- and post-HIV and STI counseling and counseling on safer sex practices and received bi-weekly text messages with reminders about the intervention. Half of the enrollees were randomly allocated to an intervention arm in which they were randomly invited to a random testing drawing. Each week over two years, ten sex workers were randomly invited to test for STIs. If they tested negative for all STIs, they received a cash award of 100,000 Tanzanian Shillings (USD $45). If a test was positive, they did not receive an award but received free STI treatment. All continued to be eligible for future drawings.
The intervention was paused during the COVID-19 pandemic, and endline interviews were completed between June 2021 and January 2022.
Research ongoing; results forthcoming.